CCA Prep Exam 2 (100 Questions)
CCA Practice Exam 2
Domain 1: Health Records and Data Content
Domain 2: Health Information Requirements and Standards
Domain 3: Clinical Classification Systems
Domain 4: Reimbursement Methodologies
Domain 5: Information and Communication Technologies
Domain 6: Privacy, Confidentiality, Legal, and Ethical Issues
Questions and Answers
- 1.
Documentation regarding a patient's marital status, dietary, sleep, and exercise patterns, use of coffee, tabacco, alcohol, and other drugs may be found in the _____________.
- A.
Physical examination record
- B.
History record
- C.
Operative report
- D.
Radiological report
Correct Answer
B. History recordExplanation
The correct answer is history record because it is a comprehensive document that includes information about a patient's personal and medical history. It typically contains details about the patient's marital status, dietary habits, sleep patterns, exercise routines, and substance use. This information is important for healthcare providers to understand the patient's lifestyle and make appropriate treatment decisions. The physical examination record focuses more on the current physical findings, while the operative and radiological reports are specific to surgical procedures and imaging results respectively.Rate this question:
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- 2.
A patient with known COPD and hypertension under treatment was admitted to the hospital with symptoms of a lower abdominal pain. He undergoes a laparoscopic appendectomy and develops a fever. The patient was subsequently discharged from the hospital with a principal diagnosis of acute appendicitis and secondary diagnoses of post-operative infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA?
- A.
Postoperative infection
- B.
Appendicitis
- C.
COPD
- D.
Hypertension
Correct Answer
A. Postoperative infectionExplanation
The postoperative infection should not be tagged as POA because it developed after the patient underwent the laparoscopic appendectomy. POA stands for Present on Admission, which means the condition was present at the time of admission to the hospital. Since the infection developed after the surgery, it is considered a complication of the procedure rather than a condition present on admission.Rate this question:
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- 3.
Which of the following would not be found in a medical history?
- A.
Chief complaint
- B.
Vital signs
- C.
Present illness
- D.
Review of systems
Correct Answer
B. Vital signsExplanation
Vital signs are not typically found in a medical history. A medical history usually includes information about the patient's chief complaint, present illness, and review of systems. Vital signs, such as blood pressure, heart rate, and temperature, are typically recorded during a physical examination or at the time of the patient's visit. They provide objective measurements of the patient's current health status and are not typically included in the medical history documentation.Rate this question:
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- 4.
Which of the following documentation must be included in a patient's medical record prior to performing a surgical procedure?
- A.
Consent for operative procedure, anesthesia report, surgical report
- B.
Consent for operative procedure, history, physical examination
- C.
History, physical examination, anesthesia report
- D.
Problem list, history, physical examination
Correct Answer
B. Consent for operative procedure, history, physical examinationExplanation
Prior to performing a surgical procedure, it is essential to have the patient's consent for the operation, as well as a thorough understanding of their medical history and physical examination. The consent for the operative procedure ensures that the patient has given their informed consent for the surgery. The history and physical examination provide crucial information about the patient's overall health status, any pre-existing conditions, and potential risks or complications that may arise during the surgery. Including these documents in the patient's medical record ensures that the healthcare team has all the necessary information to proceed with the surgical procedure safely and effectively.Rate this question:
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- 5.
Which of the following reports include names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed.
- A.
Operative report
- B.
Anesthesia report
- C.
Pathology report
- D.
Laboratory report
Correct Answer
A. Operative reportExplanation
The operative report includes the names of the surgeon and assistants, the date of the procedure, the duration of the procedure, a description of the procedure, and any specimens that were removed. This report provides detailed information about the surgical procedure that was performed, including the names of the individuals involved, the timeline of the procedure, and any relevant details about the procedure and specimens.Rate this question:
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- 6.
Identify the acute-care record report where the following information would be found: The patient is well-developed, obese male who does not appear to be in any distress, but has considerable problem with mobility. He has difficulty rising up from a chair and he uses a cane to ambulate. VITAL SIGNS: His blood pressure today is 158/86, pulse is 80 per minute, weight is 204 pounds (which is 13 pounds below what he weighed in April). He has no pallor. He has rather pronounced shaking of his arms, which he claims is not new. NECK: Showed no jugular venous distension. HEART: Very irregular. LUNGS: Clear. EXTREMITIES: Show edema of both legs.
- A.
Discharge summary
- B.
Medical history
- C.
Medical laboratory report
- D.
Physical examination
Correct Answer
D. Physical examinationExplanation
The given information describes the physical condition and vital signs of the patient, including their appearance, mobility issues, blood pressure, pulse, weight, shaking of arms, jugular venous distension, heart irregularity, clear lungs, and edema in both legs. This information is typically documented in the physical examination section of an acute-care record report.Rate this question:
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- 7.
Identify the acute care record report where the following information would be found: Gross Description: Received fresh designated left lacrimal gland is a single, unoriented, irregular tan-pink portion of soft tissue measuring 0.8 x 0.6 x 0.1 cm, which is submitted entirely, intact, in one cassette.
- A.
Discharge summary
- B.
Medical history
- C.
Medical laboratory report
- D.
Physical examination
Correct Answer
C. Medical laboratory reportExplanation
The given information describes the gross description of a specimen, specifically the left lacrimal gland. This type of information is typically found in a medical laboratory report, where the description and analysis of specimens collected during a patient's care are documented.Rate this question:
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- 8.
The clinical statement, "microscopic sections of the gallbladder reveals a surface lined by tall columnar cells of uniform size and shape" would be documented on which medical record form?
- A.
Operative report
- B.
Pathology report
- C.
Discharge summary
- D.
Nursing note
Correct Answer
B. Pathology reportExplanation
This statement would be documented on a pathology report because it describes the microscopic findings of the gallbladder. Pathology reports provide detailed information about the examination of tissues and cells, including their appearance and any abnormalities observed. In this case, the report would describe the appearance of the gallbladder lining as tall columnar cells of uniform size and shape. This information is important for diagnosing and monitoring conditions related to the gallbladder.Rate this question:
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- 9.
Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for ______________.
- A.
Performance improvement programs
- B.
Billing and claims data processing
- C.
Developing hospital discharge abstracting systems
- D.
Developing individual care plans for residents
Correct Answer
A. Performance improvement programsExplanation
Both HEDIS and the Joint Commission's ORYX program are designed to collect data for performance improvement programs. These programs aim to assess and enhance the quality of healthcare services provided by healthcare organizations. By collecting data on various performance measures, these programs enable organizations to identify areas for improvement, implement changes, and monitor the impact of those changes on patient outcomes and satisfaction. The collected data can also be used for benchmarking purposes, allowing organizations to compare their performance with national standards and best practices.Rate this question:
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- 10.
What is abstracting?
- A.
Compiling the pertinent information from the medical record based on predetermined data sets
- B.
Assigning the appropriate code or nomenclature term for categorization
- C.
Assembling a chronological set of data for an express purpose
- D.
Conducting qualitative and quantitative analysis of documentation against standards and policy
Correct Answer
A. Compiling the pertinent information from the medical record based on predetermined data setsExplanation
Abstracting refers to the process of compiling the relevant information from a medical record based on predetermined data sets. This involves extracting and gathering the necessary data points and organizing them in a systematic manner. The purpose of abstracting is to ensure that all essential information is captured and categorized appropriately for analysis and reporting purposes. It is an important step in medical record management and helps in maintaining accurate and standardized documentation.Rate this question:
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- 11.
What type of standard establishes uniform definitions for clinical terms?
- A.
Identifier standard
- B.
Vocabulary standard
- C.
Transaction and messaging standard
- D.
Structure and content standard
Correct Answer
B. Vocabulary standardExplanation
A vocabulary standard establishes uniform definitions for clinical terms. This standard ensures that healthcare professionals and systems use consistent terminology when documenting and exchanging clinical information. It helps to avoid confusion and promotes accurate communication and understanding between different healthcare entities.Rate this question:
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- 12.
According to ICD-9-CM, an elderly primigravida is defined as a woman who gives birth to her first child at the age of ______ or older:
- A.
30
- B.
35
- C.
38
- D.
40
Correct Answer
B. 35Explanation
According to ICD-9-CM, an elderly primigravida is defined as a woman who gives birth to her first child at the age of 35 or older. This means that if a woman gives birth to her first child at the age of 35 or above, she would be considered an elderly primigravida according to the ICD-9-CM classification system.Rate this question:
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- 13.
ICD-9-CM defines the "newborn period" as birth through the ___________ day following birth.
- A.
28th
- B.
14th
- C.
60th
- D.
30th
Correct Answer
A. 28thExplanation
ICD-9-CM defines the "newborn period" as birth through the 28th day following birth. This means that the classification system considers the first 28 days of a person's life as the newborn period.Rate this question:
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- 14.
"Late pregnancy" (category code 645) is used to demonstrate that a woman is over _______________.
- A.
41
- B.
39
- C.
40
- D.
42
Correct Answer
C. 40Explanation
The category code "Late pregnancy" (645) is used to indicate that a woman is over 40 weeks pregnant. This is the point at which a pregnancy is considered overdue, as a normal pregnancy typically lasts around 40 weeks. Therefore, the correct answer is 40.Rate this question:
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- 15.
Which of the following would be classified to an ICD-9-CM category for bacterial diseases?
- A.
Herpes simplex
- B.
Staphylococcus aureus
- C.
Influenza, types A and B
- D.
Candida albicans
Correct Answer
B. Staphylococcus aureusExplanation
Staphylococcus aureus would be classified to an ICD-9-CM category for bacterial diseases because it is a type of bacteria. ICD-9-CM is a coding system used to classify and categorize diseases, and bacterial diseases are a specific category within this system. Staphylococcus aureus is a common bacterium that can cause various infections in humans, such as skin infections, pneumonia, and bloodstream infections. Therefore, it would be appropriately classified under the bacterial diseases category in the ICD-9-CM coding system.Rate this question:
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- 16.
The coder notes that the physician has presribed Retrovir for the patient. The coder might find which of the following on the patient's discharge summary?
- A.
Otitis media
- B.
AIDS
- C.
Toxic shock syndrome
- D.
Bacteremia
Correct Answer
B. AIDSExplanation
The coder would find AIDS on the patient's discharge summary because Retrovir is a medication used to treat HIV infection, which is the underlying cause of AIDS.Rate this question:
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- 17.
What diagnosis would the coder expect to see when a patient with pneumonia (PNA) has inhaled food, liquid, or oil?
- A.
Lobar pneumonia
- B.
Pneumocystitis carinii pneumonia
- C.
Interstitial pneumonia
- D.
Aspiration pneumonia
Correct Answer
D. Aspiration pneumoniaExplanation
When a patient with pneumonia inhales food, liquid, or oil, the coder would expect to see a diagnosis of aspiration pneumonia. Aspiration pneumonia occurs when foreign material, such as food or liquid, is inhaled into the lungs, leading to infection and inflammation. This can happen when a person has difficulty swallowing or coughs while eating or drinking, causing the material to enter the airway instead of the digestive system. Aspiration pneumonia typically presents with symptoms such as cough, chest pain, fever, and difficulty breathing.Rate this question:
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- 18.
Where would a coder who needed to locate the histology of a tissue sample most likely find this information
- A.
Pathology report
- B.
Progress notes
- C.
Nurse's notes
- D.
Operative report
Correct Answer
A. Pathology reportExplanation
A coder who needs to locate the histology of a tissue sample would most likely find this information in a pathology report. A pathology report is a document that contains detailed information about the examination of tissues and cells under a microscope. It provides information about the type of tissue, any abnormalities or diseases present, and the histological characteristics of the sample. Therefore, the pathology report is the most appropriate source for the coder to find the histology of a tissue sample.Rate this question:
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- 19.
The coder notes the patient is taking prescribed Haldol. The final diagnoses on the progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What condition might the coder suspect the patient has and should query the physician?
- A.
Insomnia
- B.
Hypertension
- C.
Schizophrenia
- D.
Rheumatoid arthritis
Correct Answer
C. SchizophreniaExplanation
Based on the information provided, the coder notes that the patient is taking prescribed Haldol, which is an antipsychotic medication commonly used to treat schizophrenia. Therefore, the coder might suspect that the patient has schizophrenia and should query the physician for confirmation or further information.Rate this question:
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- 20.
Which organization developed the first hospital standardization program?
- A.
Joint Commission
- B.
American Osteopathic Association
- C.
American College of Surgeons
- D.
American Association of Medical Colleges
Correct Answer
C. American College of SurgeonsExplanation
The American College of Surgeons developed the first hospital standardization program. This program aimed to establish consistent and high-quality medical practices in hospitals. It played a crucial role in improving patient care and safety by setting standards for surgical procedures, training, and hospital management. The program has since been adopted by various healthcare organizations worldwide to ensure excellence in surgical care.Rate this question:
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- 21.
The hospital is revising its policy on medical record documentation. Currently, all entries in the medical record must be legible, complete, dated, and signed. The committee chairperson wants to add that, in addition, all entries must have the time noted. However, another clinician suggests that adding the time of notation is difficult and rarely may be correct since personal watches and hospital clocks may not be coordinated. Another committee member agrees and says only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM direct suggest?
- A.
Suggest that only hospital clock time be noted in clinical documentation
- B.
Suggest that only electronic documentation have time notated
- C.
Inform the committee that according to the Medicare Conditions of Participation all documentation must be authenticated and dated
- D.
Inform the committee that according to the Medicare Conditions of Participation only medication orders must include date and time
Correct Answer
C. Inform the committee that according to the Medicare Conditions of Participation all documentation must be authenticated and datedExplanation
The correct answer suggests that the HIM should inform the committee that according to the Medicare Conditions of Participation, all documentation must be authenticated and dated. This means that regardless of whether the time is noted or not, the entries in the medical record must be authenticated and dated. This response addresses the concerns raised by the committee members about the difficulty of noting the time and the potential lack of coordination between personal watches and hospital clocks.Rate this question:
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- 22.
When correcting erroneous information in a health record, which of the following is not appropriate?
- A.
Print "error" above the entry
- B.
Enter the correction in chronological sequence
- C.
Add the reason for the change
- D.
Use black pen to obliterate the entry
Correct Answer
D. Use black pen to obliterate the entryExplanation
Using a black pen to obliterate the entry is not an appropriate method for correcting erroneous information in a health record. This is because obliterating the entry makes it difficult to read and can create confusion. Instead, the correct approach would be to print "error" above the entry to indicate that it is incorrect, enter the correction in chronological sequence, and add the reason for the change.Rate this question:
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- 23.
Community Hospital implemented a clinical document improvement (CDI) program six months ago. The goal of the program was to improve clinical documentation to support quality of care, data quality, and HIM coding accuracy. Which of the following would be best to ensure that everyone understands the importance of this program?
- A.
Request that the CEO write a memorandum to all hospital staff
- B.
Give the chairperson of the CDI committee authority to fire employees who don't improve their clinical documentation
- C.
Include ancillary clinical and medical staff in the process
- D.
Request a letter from the Joint Commission
Correct Answer
C. Include ancillary clinical and medical staff in the processExplanation
Including ancillary clinical and medical staff in the process would be the best way to ensure that everyone understands the importance of the CDI program. By involving these staff members, they will have a direct role in the program and will be able to see the impact of their documentation on the quality of care, data quality, and coding accuracy. This will help them understand the importance of accurate and thorough clinical documentation and will encourage their active participation and support for the program.Rate this question:
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- 24.
In a routine health record quantitative analysis review it was fund that a physician dictated a discharge summary on 1/26/2009. The patient, however, was discharged two days later. In this case, what would be the best course of action?
- A.
Request that the physician dictate another discharge summary
- B.
Have the record analyst note the date discrepancy
- C.
Request the physician dictate an addendum to the discharge summary
- D.
File the record as complete since the discharge summary includes all the pertinent patient information
Correct Answer
C. Request the physician dictate an addendum to the discharge summaryExplanation
The best course of action in this case would be to request the physician to dictate an addendum to the discharge summary. This is because the discharge summary was dictated on 1/26/2009, but the patient was actually discharged two days later. By requesting an addendum, the physician can provide an updated summary that reflects the correct date of discharge. This ensures that the health record is accurate and complete.Rate this question:
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- 25.
During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the legal principle that documentation must occur near the time of the event. To remedy this situation, the HIM director should recommend which of the following?
- A.
Immediately stop the practice of changing transcribed reports
- B.
Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form
- C.
Conduct a verification audit
- D.
Alert hospital legal counsel of the practice
Correct Answer
B. Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft formExplanation
The HIM director should recommend developing a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form. This will help establish a clear guideline for how long a transcribed document can be changed after initial transcription, ensuring that documentation occurs near the time of the event as required by the legal principle. This policy will help prevent any potential legal issues and maintain the integrity of the health records.Rate this question:
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- 26.
During a review of documentation practices, the HIM director finds that nurses are routinely using the copy and paste function of the hospital's new EHR system for documenting nursing notes. In some cases, nurses are copying and pasting the objective data from the lab system and intake-output records as well as the patient's subjective complaints and symptoms originally documented by another practitioner. Which of the following should the HIM director do to ensure the nurses are following acceptable documentation practices?
- A.
Inform the nurses that "copy and paste" is not acceptable and to stop this practice immediately
- B.
Determine how many nurses are involved in this practice
- C.
Institute an in-service training session on documentation practices
- D.
Develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system
Correct Answer
D. Develop policies and procedures related to cutting, copying, and pasting documentation in the EHR systemExplanation
The HIM director should develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system. This will provide clear guidelines for the nurses on how to appropriately use the copy and paste function. By implementing these policies, the HIM director can ensure that the nurses understand the acceptable documentation practices and prevent any potential issues or errors that may arise from improper use of the function.Rate this question:
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- 27.
Who is responsible for writing and signing discharge summaries and discharge instructions?
- A.
Attending physician
- B.
Head nurse
- C.
Primary physician
- D.
Admitting nurse
Correct Answer
A. Attending physicianExplanation
The attending physician is responsible for writing and signing discharge summaries and discharge instructions. This is because the attending physician is the primary physician who has been directly involved in the patient's care throughout their hospital stay. They have the knowledge and expertise to accurately summarize the patient's medical condition, treatment, and future care instructions. The attending physician's signature on these documents ensures their accountability and provides a clear communication to the patient and the healthcare team involved in the patient's follow-up care.Rate this question:
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- 28.
Dr. Jones has signed a statement that all of her dictated reports should be automatically considered approved and signed unless she makes correction within 72 hours of dictating. This is called _____________.
- A.
Autoauthentication
- B.
Electronic signature
- C.
Automatic record completion
- D.
Chart tracking
Correct Answer
A. AutoauthenticationExplanation
Autoauthentication refers to the process where Dr. Jones' dictated reports are automatically considered approved and signed unless she makes corrections within 72 hours of dictating. This means that the reports are authenticated automatically without the need for manual approval or signature.Rate this question:
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- 29.
The discharge summary must be completed within ________ after discharge for most patients but within __________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than __________ hours.
- A.
30 days / 48 hours / 24 hours
- B.
14 days / 24 hours / 48 hours
- C.
14 days / 48 hours / 24 hours
- D.
30 days / 24 hours / 48 hours
Correct Answer
D. 30 days / 24 hours / 48 hoursExplanation
The discharge summary must be completed within 30 days after discharge for most patients but within 24 hours for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than 48 hours.Rate this question:
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- 30.
Which of the following is not an accepted accrediting body for behavioral healthcare organizations?
- A.
American Psychological Association
- B.
Joint Commission
- C.
Commission on Accreditation of Rehabilitation Facilities
- D.
National Committee for Quality Assurance
Correct Answer
A. American Psychological AssociationExplanation
The American Psychological Association (APA) is not an accepted accrediting body for behavioral healthcare organizations. While the APA is a professional organization that sets ethical standards and guidelines for psychologists, it does not specifically accredit healthcare organizations. The Joint Commission, Commission on Accreditation of Rehabilitation Facilities (CARF), and National Committee for Quality Assurance (NCQA) are all recognized accrediting bodies in the healthcare industry.Rate this question:
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- 31.
What type of standard establishes methods for creating unique designations for individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers?
- A.
Vocabulary standard
- B.
Identifier standard
- C.
Structure and content standard
- D.
Security standard
Correct Answer
B. Identifier standardExplanation
The correct answer is "Identifier standard". An identifier standard establishes methods for creating unique designations for individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers. This standard ensures that each entity in the healthcare system can be identified accurately and consistently, allowing for effective communication, record-keeping, and coordination of care.Rate this question:
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- 32.
What type of organization works under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals?
- A.
Accreditation organizations
- B.
Certification organizations
- C.
State licensure agencies
- D.
Conditions of participation agencies
Correct Answer
C. State licensure agenciesExplanation
State licensure agencies work under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals. These agencies are responsible for ensuring that healthcare facilities meet the necessary standards and regulations to participate in these government-funded healthcare programs. They conduct surveys and inspections to assess the quality of care provided by hospitals and determine their eligibility for reimbursement from Medicare and Medicaid.Rate this question:
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- 33.
Which of the following specialized patient assessment tools must be used to Medicare-certified home care providers?
- A.
Patient Assessment Instrument
- B.
Minimum Data Set for Long-Term Care
- C.
Resident Assessment Protocol
- D.
Outcomes and Assessment Information Set
Correct Answer
D. Outcomes and Assessment Information SetExplanation
The Outcomes and Assessment Information Set (OASIS) must be used by Medicare-certified home care providers. OASIS is a specialized patient assessment tool that is used to collect data on patients receiving home health services. It is designed to measure patient outcomes and facilitate quality improvement initiatives. OASIS is used to assess the patient's physical, psychological, and social functioning, as well as their health status and service needs. It is a crucial tool for Medicare-certified home care providers to ensure accurate and comprehensive assessment of their patients.Rate this question:
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- 34.
Identify the correct sequence and ICD-9-CM diagnosis code(s) for a patient with a scar on the right hand secondary to a laceration sustained two years ago.
- A.
709.2
- B.
906.1
- C.
709.2, 906.1
- D.
906.1, 709.2
Correct Answer
C. 709.2, 906.1Explanation
Late affect would never be the first diagnosisRate this question:
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- 35.
Identify the correct sequence and ICD-9-CM diagnosis code(s) for a patient with dysphasia secondary to old cerebrovascular accident sustained one year ago.
- A.
787.20, 438.12
- B.
784.59, 438.12
- C.
438.12
- D.
787.20, 438.89
Correct Answer
C. 438.12Explanation
The correct answer is 438.12. This code represents the diagnosis of dysphasia secondary to an old cerebrovascular accident sustained one year ago. The code 438.12 specifically identifies the late effects of cerebrovascular disease, which includes dysphasia. The other options do not accurately capture the specific diagnosis and the relationship to the cerebrovascular accident.Rate this question:
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- 36.
Identify the correct ICD-9-CM diagnosis code(s) for a patient with nausea, vomiting, and gastroenteritis.
- A.
558.9
- B.
787.01, 558.9
- C.
787.02, 787.03, 558.9
- D.
787.01, 558.41
Correct Answer
A. 558.9Explanation
The correct ICD-9-CM diagnosis code for a patient with nausea, vomiting, and gastroenteritis is 558.9. This code represents noninfectious gastroenteritis and colitis, unspecified. It is the most appropriate code given the symptoms described in the question.Rate this question:
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- 37.
Identify the correct ICD-9-CM diagnosis code for a patient with an elevated prostate specific antigen (PSA) test result.
- A.
796.4
- B.
790.6
- C.
792.9
- D.
790.93
Correct Answer
D. 790.93Explanation
The correct ICD-9-CM diagnosis code for a patient with an elevated prostate specific antigen (PSA) test result is 790.93. This code is used for abnormal PSA levels, indicating a potential issue with the prostate. The other options are not specific to PSA test results or prostate-related conditions.Rate this question:
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- 38.
Identify the correct ICD-9-CM diagnosis code(s) for a patient with near-syncope event and nausea.
- A.
780.2
- B.
780.2, 787.02
- C.
780.2, 787.01
- D.
780.4, 787.02
Correct Answer
B. 780.2, 787.02Explanation
The correct ICD-9-CM diagnosis code(s) for a patient with near-syncope event and nausea are 780.2 and 787.02. The code 780.2 represents the diagnosis of syncope and pre-syncope, which includes near-syncope. The code 787.02 represents the diagnosis of nausea. Therefore, both codes are necessary to accurately represent the patient's symptoms.Rate this question:
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- 39.
Identify the correct ICD-9-CM diagnosis code(s) for a patient with abnormal glucose tolerance test.
- A.
790.29
- B.
790.21
- C.
790.21, 790.29
- D.
790.22
Correct Answer
D. 790.22Explanation
The correct ICD-9-CM diagnosis code for a patient with abnormal glucose tolerance test is 790.22. This code is used for the diagnosis of impaired glucose tolerance, which indicates an abnormal response to a glucose tolerance test. The other options (790.29, 790.21, and 790.21, 790.29) do not specifically indicate abnormal glucose tolerance and are therefore not the correct codes for this diagnosis.Rate this question:
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- 40.
Identify the correct ICD-9-CM diagnosis code(s) for a patient with pneumonia and persistent cough.
- A.
786.2, 490
- B.
486, 786.2
- C.
486
- D.
481
Correct Answer
C. 486Explanation
The correct ICD-9-CM diagnosis code for a patient with pneumonia and persistent cough is 486. This code specifically represents pneumonia, which is the primary diagnosis, and includes the symptom of persistent cough. The other options either do not include the symptom of persistent cough or do not specifically represent pneumonia as the primary diagnosis.Rate this question:
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- 41.
Identify the correct ICD-9-CM diagnosis code(s) for a patient with seizures; epilepsy, ruled out.
- A.
780.39
- B.
345.9
- C.
780.39, 345.9
- D.
345.90
Correct Answer
A. 780.39Explanation
The correct ICD-9-CM diagnosis code for a patient with seizures and epilepsy ruled out is 780.39. This code is used to indicate other convulsions and related conditions, excluding epilepsy. It is important to accurately document and code the patient's condition to ensure proper diagnosis and treatment.Rate this question:
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- 42.
Identify the correct ICD-9-CM diagnosis code for a male patient with stress urinary incontinence.
- A.
625.6
- B.
788.30
- C.
788.32
- D.
788.39
Correct Answer
C. 788.32Explanation
The correct ICD-9-CM diagnosis code for a male patient with stress urinary incontinence is 788.32. This code specifically represents stress incontinence, which is the involuntary leakage of urine during activities that put pressure on the bladder, such as coughing, sneezing, or lifting heavy objects.Rate this question:
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- 43.
Identify the correct ICD-9-CM diagnosis code(s) for a patient with right lower quadrant abdominal pain with nausea, vomiting, and diarrhea.
- A.
789.03
- B.
789.03, 787.02, 787.03, 787.91
- C.
789.03, 787.91
- D.
789.03, 787.01, 787.91
Correct Answer
D. 789.03, 787.01, 787.91Explanation
The correct ICD-9-CM diagnosis code(s) for a patient with right lower quadrant abdominal pain with nausea, vomiting, and diarrhea are 789.03, 787.01, 787.91. This is because 789.03 represents the abdominal pain, 787.01 represents the nausea and vomiting, and 787.91 represents the diarrhea.Rate this question:
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- 44.
Identify the punctuation mark that is used to supplement words or explanatory information that may or may not be present in the statement of diagnosis or procedure in ICD-9-CM coding. The punctuation does not affect the code number assigned to the case. The punctuation is considered a nonessential modifer, and all three volumes of ICD-9-CM use them.
- A.
Parentheses ( )
- B.
Square brackets [ ]
- C.
Slanted brackets [ ]
- D.
Braces { }
Correct Answer
A. Parentheses ( )Explanation
Parentheses ( ) are used to supplement words or explanatory information that may or may not be present in the statement of diagnosis or procedure in ICD-9-CM coding. The use of parentheses does not affect the code number assigned to the case. They are considered a nonessential modifier, and all three volumes of ICD-9-CM use them.Rate this question:
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- 45.
From the health record of a patient newly diagnosed with a malignancy: Preoperative Diagnosis: Suspicious lesions, main bronchus Postoperative Diagnosis: Carcinoma, in situ, main bronchus Indications: Previous bronchoscopy showed two suspicious lesions in the main bronchus. Laser photoresection is planned for destruction of these lesions, because bronchial washings obtained previously showed carcinoma in situ. Procedure: Following general anesthesia in the hospital same-day surgery area, with a high-frequency jet ventilator, a rigid bronchoscope is inserted and advanced through the larynx to the main bronchus. The areas were treated with laser photoresection. Identify the ICD-9-CM diagnosis code and CPT procedure code(s) for this service?
- A.
162.2, 31641, 31623-59
- B.
231.2, 31641, 31623-59
- C.
231.2, 31641
- D.
162.2, 31641
Correct Answer
C. 231.2, 31641Explanation
The correct answer is 231.2, 31641. The preoperative diagnosis of "Suspicious lesions, main bronchus" is coded as 231.2, which represents carcinoma in situ of the bronchus. The procedure code 31641 is used for laser photoresection of the bronchus.Rate this question:
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- 46.
A 22-year-old patient presents for a closure of a patent ductus arteriosus. The patient's thorax is opened posteriorly and the vagus nerve is isolated away. The PDA is divided and sutured individually in the aorta and pulmonary artery. How is this procedure coded?
- A.
33813
- B.
33820
- C.
33822
- D.
33824
Correct Answer
D. 33824Explanation
The correct answer is 33824 because this code is used for the closure of a patent ductus arteriosus (PDA) through a thoracotomy approach. In this procedure, the vagus nerve is isolated and the PDA is divided and sutured individually in the aorta and pulmonary artery. The other options (33813, 33820, 33822) do not specifically describe the closure of a PDA through a thoracotomy approach.Rate this question:
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- 47.
Identify the correct ICD-9-CM diagnosis code for a patient with anterolateral wall myocardial infarction, initial episode.
- A.
410.11
- B.
410.01
- C.
410.02
- D.
410.12
Correct Answer
B. 410.01Explanation
The correct ICD-9-CM diagnosis code for a patient with anterolateral wall myocardial infarction, initial episode is 410.01. This code specifically denotes an acute myocardial infarction of the anterolateral wall.Rate this question:
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- 48.
Identify the correct ICD-9-CM diagnosis code(s) and sequence for a patient with disseminated candidiasis secondary to AIDS-like syndrome.
- A.
042, 112.4, V01.79
- B.
112.4, 042
- C.
042, 112.4, V08
- D.
042, 112.4
Correct Answer
D. 042, 112.4Explanation
The correct ICD-9-CM diagnosis code(s) and sequence for a patient with disseminated candidiasis secondary to AIDS-like syndrome are 042 and 112.4. This is because code 042 represents the HIV infection, which is the underlying cause of the AIDS-like syndrome, and code 112.4 represents the disseminated candidiasis. These two codes should be sequenced in that order to accurately represent the relationship between the two conditions. The other options either do not include the correct codes or do not have the correct sequencing.Rate this question:
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- 49.
Identify the correct ICD-9-CM diagnosis code(s) and proper sequencing for urinary tract infection due to E. coli.
- A.
599.0
- B.
599.0, 041.4
- C.
041.4
- D.
041.4, 599.0
Correct Answer
B. 599.0, 041.4Explanation
The correct ICD-9-CM diagnosis code for urinary tract infection due to E. coli is 599.0. Additionally, code 041.4 should be sequenced after 599.0 to indicate the specific organism causing the infection.Rate this question:
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- 50.
Identify the correct ICD-9-CM diagnosis codes and sequence for a patient who was admitted to the outpatient chemotherapy floor for acute lymphocytic leukemia. During the procedure, the patient developed severe nausea with vomiting and was treated with medications.
- A.
204.00, 787.01, V58.11
- B.
V58.11, 204.00, 787.01
- C.
V58.11, 204.00
- D.
204.22, 787.01
Correct Answer
B. V58.11, 204.00, 787.01Explanation
The correct ICD-9-CM diagnosis codes and sequence for a patient who was admitted to the outpatient chemotherapy floor for acute lymphocytic leukemia are V58.11, 204.00, 787.01. The code V58.11 indicates the encounter for antineoplastic chemotherapy, while 204.00 represents acute lymphocytic leukemia, and 787.01 represents nausea with vomiting. This sequence follows the guidelines of coding the primary diagnosis first, followed by any secondary diagnoses or symptoms.Rate this question:
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Dec 21, 2011Quiz Created by
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